The DIGITAL PROGRESSION OF RADIOLOGY

Alyn Ford and Carsten G. Weise(*)

International Sales & Marketing Manager Impax,
(*) Communications Manager Agfa MED/IDIS

Mortsel, Belgium

à     Healthcare reforms which create financing and cost pressures. Public demand outpaces the ability of world economies to fund the (healthcare) process. Healthcare needs to become more effective and at the same time more (cost) efficient.

à     The consolidation of medical services. The merging of corporate entities and the consolidation of services creates the need for information sharing that can only be provided by the digital exchange of data.

At a time of significantly reduced funding for healthcare across the world, why should radiology departments invest in new technologies like PACS? Do departments really need such systems? Will PACS lower costs and deliver better healthcare? How should internal processes be revised in anticipation of the system? And how can departments ensure that a PACS system operates as expected?

As the market leader in PACS technology, Agfa has gained an insight into the healthcare market, PACS justification, implementation and system integration.

Agfa has over 300 world PACS sites (and counting) with IMPAX digital diagnostic imaging systems, and is gaining a comprehensive understanding of the needs and concerns, the triumphs and pitfalls of healthcare professionals as they get up to speed with PACS.

Justification:

Before tackling the first stage, justification, it's important to understand the context in which decisions about PACS systems are made. Radiology budgets haven't been immune from the cuts in healthcare funding. There's obviously less money available for film and capital expenditures.

In the past, many general department PACS systems have been heavily subsidized by commercial interests. Or they've been paid for by capital funding mechanisms, with a financial payback beyond the 3-5-year time frame. To day, hospital administrators are demanding that radiology departments work with their lowest funding levels ever. Institutions need an operational system that works with fewer dollars per patient.

Considering PACS in this context, it's evident that justification for the system must be built around more than just reducing film. That's no longer enough to rationalize the capital investment -- not when we consider the operational costs for service and software/hardware upgrades required to operate these new systems.

Operational design changes within radiology that create efficiencies are now dependent on areas outside the radiology department (OR, ER, Ambulatory Care, etc.) for their ultimate success. You can only reduce film consumption by reducing the demand for film from the professional customers of radiology.

Radiology must prove the value of the system to these other hospital areas, so they'll invest their time and money to access the images and reports they've requested. PACS must be as efficient for these other areas as their current systems, or else it simply won't be used.

So how can institutions be convinced to invest in PACS, in light of the intense competition for capital dollars? More often than not, PACS, as a technology, gets mixed in with competing capital purchase needs in institutions. In fact, it's only one of several elements within the telemedicine or Integrated Delivery System (IDS) model.

Approaching funding authorities -- whether the CEO or external funding partners --without a clear strategy is a grave mistake. It's critical these days to be sure you have a clear strategy that fits the global strategic direction of your institution before you start to sell the technology of the boxes that will create your PACS network. With a strong and mutually-agreed upon strategy the direction of an institution will be perpetuated.

In the IDS model, activities can be organized into information generation and information extraction (an integration of both is another activity). The key is to be able to clearly represent where PACS fits in the institutional and community health strategies.

Truly efficient information sharing will not happen until the "libraries" have digital information in the form of diagnostic images and related health records. Once the on-line libraries have this information, authorized access can be provided to users. Institutions that create information libraries will generate the demand for that information. In putting a library in place, they will perpetuate and increase their future value.

The IDS world revolves around a couple of fundamental rules

à     first, the IDS serves the patient better by increasing the effectiveness, efficiency and speed of healthcare delivery;

à     second, information is the prime currency; those that control it will direct healthcare information sharing activities. Those that do not control it will follow the direction of those that do.

By focusing on the plan to secure information (images and related records) and share as needed, the PACS investment comes to the forefront. This thought can galvanize the attention of an institution, making it easier to move to the more traditional justifications -- how much film will you reduce, how will work processes change, how much space will be gained, and so on.

An IDS can serve the patient better by increasing the effectiveness, efficiency and speed of healthcare delivery. And information is the prime currency. This strategic justification goes beyond the traditional justifications (film reduction, changed work processes, space gains, etc.) and assesses the impact on the total delivery system.

Implementation:

Now that you've managed to justify your PACS purchase, just how do you ensure that the system is implemented as planned?

All too often, it’s not. In fact, the system discussed during negotiations can often take longer to implement than planned, or may even end up delivering less than expected when it’s complete. Why does this happen? There are two primary reasons: Underestimating the behavior changes required to implement a PACS network; and failing to prepare -- and follow -- a comprehensive implementation plan.

Some examples of things to think about before PACS implementation:

à     How do orthopaedic surgeons manage image information? Is there a better way?

à     Can we speed up the information exchange?

à     Have we estimated the hardware requirements properly for the ambulatory care clinic?

à     Are the users computer literate? Are they interested in the success of the change required?

à     Does the PACS project have an internal champion?

Although the implementation of a PACS system is complex and challenging, it is manageable. The knowledge, experience and creativity that forges the strategic plan will be the force that increases the probability of success.

Integration:

Is your PACS project working as anticipated? Is your institution achieving the cost /efficiency savings expected? And is the partnership between the hospital and the vendor operating to full advantage? Those are among the key questions facing diagnostic imaging departments and their hospitals as the transition to PACS technology speeds ahead.

Judging the technical performance is the easy part. Does the system match or exceed the specifications laid out in the technical section of the Request for Proposal or Tender? Unfortunately, specific technical performance of single components within a complex system —whether good or bad — can be hidden or augmented by the total systemic performance. And what if the desired technical performance simply isn't happening? Do you have the ability to seek restitution from the supplier, either as per the terms of the RFP, or just as part and parcel of the ongoing relationship you have with the supplying vendor?

The hard part is determining if you're achieving the systemic performance goals of the PACS project. First, you can only recognize if you' re reaching your performance goals if you understand the performance of the system before the adoption of new technologies. Should be simple, right? Except that getting a reliable fix on that performance can be tricky. The budget of a radiology department, and certainly the budget of the institution, can be complex creatures. Complex enough that performance benefits can be swallowed within the fluctuations of other financial changes and variations.

Only by quantifying the financial and workflow effect in a department can the "real" savings be credibly identified. Again, that's easier said than done. Beyond the direct savings and comparisons of technology, there's the question of the larger financial impact. That is, of course, the effect on workflow and process in the departments and areas outside radiology.

These efficiencies can be understood and represented in a financial manner, but it requires the direct involvement of the departments involved in the change. That’s why it’s important to include all parties who will be affected as soon in the process as possible, and why it’s key that the PACS project have an internal champion.

With these elements in place, you’ll be able to achieve a broader, more realistic understanding of the return on the PACS investment.

The ability to verify the promised deliverable is, in fact, a key element in building a stronger relationship between the commercial supplier and the institution. Cooperatively owning the strategic plan for the success of the project is an effective way for both parties to build ownership for the outcomes.

Lastly, it’s important that the project goals are realistic, with reasonable time frames. The idea of developing product ‘on the fly’ is at once romantic and alluring, but at the same time may be more demanding than expected.

The partners in the project must be very honest with each other, and be sure the plan is reasonable. It is this shared ownership commitment that will beat the root of the success of the project.

Summary:

The gradual growth of Radiology along digital detectors towards a full electronic department will activate the negotiation between the radiologist and the hospital management about the role to be played by Radiology. Here the radiologist has to consider himself as the best partner and the largest user of hospital networks, taking a leading role in the development of information technology in the hospital, and using the right arguments.

And that is the ultimate proof that this technology is worthwhile. Whether they specialize in children or in adults, Agfa is privileged to be accompanying our customers as they move forward towards the future, and we are resolved that they shall never have cause to look back with any regrets at the conventional systems they have left behind.

Oral presentation at EuroPACS'98, Barcelona, Spain